Family Centered Care and Pain Flashcards
Family
A group of individuals who share a legal or genetic bond, but for many it means much more
Legal bond
A family thats legally bound through marriage, adoption, guardians, and includes the rights, duties, obligations, and contracts that they entered in to
Can be changed, expanded or dissolved
Blood bonds
individuals who are directly related through a common ancestor
Close and distant realtives
Types of family
Nuclear or Conjugal Extended Complex Step Traditional Adopted Foster
Nuclear or Conjugal family
Parents and their children living in the same residence or sharing the closest of bonds
Extended
Includes all relatives being in close proximity (generations: X, Y, Z) where relatives live maybe not next door to each other, but in the same city
Household that is extended: these families can live together and share household duties, also called joint family or multigenerational family depending on which member are included
Complex
Extended family which has 3 or more adults + their children
Formed through divorce and remarriage or may be formed through polygamy in societies where that practice is acceptable
Families may be complex without formal legal binds between adults
Step
Families where adults have divorced and remarried bringing children from other unions together to form a new nuclear family
Called blended family
May come from several different parents or may be new to the family
Traditional
Classical family
Father works outside of the household to support the members financially while the mom stays at home and raises the children and takes care of them
Roles may be reversed
Adopted
Family shares legal bond but not genetics
Can be emotional or spiritual bond where no formal legal bonds are present
Foster
Includes one or more adult parents who serve as temporary guardians for one or more children to whom they may or may not be biologically related to
More formal arrangements may be made
Foster children can be legally adopted
Enabling
When we can enable a family through education and practice to acquire the competencies they require to take care of their child, they are able to meet the needs of their family
Empowerment
Returns to the family a sense of control
This is something we can give to the family– a sense of control that they had lost when their child got sick
Family Centered Care Basic concepts:
Enabling
Empowering
Control
Communication
Communication
When we communicate, we offer education, we foster and honor the families sense of strength, abilities, and action
The family that will be taking care of the child upon discharge
Its imperative that we give them these skills, knowledge, and encouragement
Promoting Healthy Families
Disease prevention
Health promotion
The family is the driver
Family Centered Care: Best approaches
Education
Anticipatory Guidance
Education
Important that we helpguide families through the stages of child growth and development and milestones of each age
If we identify problems early we can get better outcomes
Anticipatory Guidance
Help the family understand the medical treatment and diagnosis
Encouraging the children to ask questions about their bodies and conditions, referring families appropriately to agencies or support groups
ABOVE ALL COMMUNICATE!
Parenting Styles
Authoritarian
Authoritative
Permissive/Indulging
Uninvolved
Parenting Styles: Authoritarian
Children are expected to follow very strict rules established by the parent and a failure to follow these rules will result in punishment
“Because I said so” parents
Often fails parents because they aren’t giving reasoning to. children about the action, so the children don’t understand why they are doing what they are doing
Parents have very high demands, children are not responsive
Children are obedient and proficient but often in test show lower confidence/self-esteem, happiness, and social competence than other children
Parenting Styles: Authoritative
Like Authoritarian, having guidelines that they expect their children to follow, however they are more democratic
Responsive to their children and are willing to listen to their questions
More nurturing and when their children fail, they often are more forgiving and don’t give heavy/strict punishment
Assertive but not restrictive or intrusive
Disciplinary methods aren’t necessarily punitive
Desire their children to be assertive, socially responsible, and cooperative
Children are usually very happy, capable, and successful in their lives
Parenting Styles: Permissive/Indulging
Parents make very few demands of their children
Rarely discipline children
Have low expectations of maturity and self-control
Non-traditional parents and are very lenient
Will avoid confrontation
Can be nurturing and communicative, but they are more like a friend and not a parent
Almost like they are living through their children
Children rank low in happiness and self-regulation, have problems with authority and perform poorly in school
Parenting Styles: Uninvolved
Parent place very few demands on children
Not alot of responsiveness and there is little communication
Fulfill the child’s basic needs, but are detached
Extreme cases: they may reject or neglect their child’s needs
Children lack self control, low self-esteem, and are less competent than their peers
Parenting influences
Key characteristics parents should always exhibit when working with their children
Engagement
Consistency
Validation
Engagement
Need to be engaged
Invested in childs activities
Spending quality time with child
Consistency
Must be consistent in what they do with children
Cant deviate
Children need consistency, so that they know what it is that they are expected to do and can do
Validation
Builds self-esteem
Validate: feelings (even if they seem inconsequential or idiotic), fears (its ok to be scared but you will work through the fear), and all other emotions
Children see thing differently
Parental Guildlines
Safety
Realistic expectations
Discipline
Pediatric choices
Safety
Most important to address with parents
Realistic expectations
of their children and self
Discipline
how to incorporate into family setting, knowing when its appropriate to use it
Focus on the importance of consistency
Focus on positive reinforcement and NOT negative reinforcement
Pediatric choices
Parents need to be careful what they offer the child
These influences can be tremendous
Children that spend alot of time with their parents are directly influenced by their behaviors, choices, and beliefs
Family Stressors
A sick child could be the first crisis that the family faces
Depended on: Severity of illness, Frequent flyer, Medical procedures, coping abilities, cultural/religious beliefs
Frequent flyer
Do they have previous experience with illness/hospitalization?
Sometimes they know what to expect, it can be a stressor because if something different happens, then they know disease has progressed
Coping abilities
What are their personal strengths?
Family support system?
Other stressors are on the family system?
Common themes in families with hospitalized children
Families become helpless, they question the skills of the staff, they don’t understand/hear because they are stressed (you must reinforce teachings, use simple explanations
They need their fears and uncertainty respected
They need reassurance
They need to see the staff being compassionate and concerned for their child, attending to every detail
Sibling response
Lives are turned upside down
Become scare, lonely, and angry
Start noticing their parents pay more attention to the sick child and become jealous and resent their sick sibling, then they feel guilty for the jealousy
Behavior often regresses to that of a previous developmental stage (its ok)
These children need someone to talk to them about their siblings situation because they are emotionally stressed out
Children and hospitalizations
Young children are vulnerable to stress and are so used to a routine and may not have the coping mechanisms necessary to deal with this new situation
Children and hospitalizations: Children’s Experience
Parental separation
Loss of control
They dont feel well and they dont understand why, and dont understand fear
Children and hospitalizations: Parent Experience
Fear of whats happening to their child, guilt, confusion, loss of routine, loss of control
Children and hospitalizations: Most common things seen
regression separation anxiety apathy fear sleep disturbances especially in children <7
Children and hospitalizations: Other factors that make hospitalization difficult
Children with difficult temperament (age? More temperamental between 6mo and 5yr)
Gender
Do they have a low IQ
Frequent flyer syndrome
Children and hospitalizations: Infants
Pain is not localized but generalized to them and they are totally in pain
Make sure to relieve the pain
Loss of routine
Sleep deprivation
Vulnerable immune system because they have not been able to have most of their vax
Children and hospitalizations: Toddlers
Basic fear of loss of love, the unknown
They wonder if they are being punished
Immobilization and isolation will influence their physical and psychosocial development
Can regress to earlier behaviors and will go through the stages of separation anxiety
Children and hospitalizations: Separation anxiety
Protest
Despair
Detachment or denial of whats going on
Children and hospitalizations: Protest
they will not be consoled by the parents
they want to go home
reject strangers or new nurses
Children and hospitalizations: Despair
Sleep pattern will alter
Lose weight because they wont eat
Have diminished interest in play
Sad and unresponsive to stimuli
Children and hospitalizations: Detachment or Denial of whats going on
Wont acknowledge their parents
They’ll be friendly to other people who come along
Children and hospitalizations: Preschoolers
Have fears about their body image and bodily harm
Have a limited understanding of what s going on
Their fears are about intrusive things like IVs or shots or tubes
Have the same perception of punishment and rejection
Worry about pain and that they wont look the same
Also regress
View death as temporary
Cry when parents leave but will calm down after they are gone
May find physical exams threatening and so you may have to modify your procedures
Children and hospitalizations: School age
Tolerate separation but really want their parents to be near
Fear the unknown, bodily harm, and disfigurement
Concept of death changes at this time (6-8yr/o: death is the boogieman, 9-10yr/o: death is more realistic)
Very concerned about their self image and may even use avoidance to cope with physical discomfort
Want to know whats going on, the rationale, and want to participate in self care
Children and hospitalizations: Adolescents
Be honest
They have concerns about their privacy, sense of control, and independence
Very concerned about their body image and being different than their peer
Developmental problems that might be going on are magnified by their illness
Can be non-compliant
Worry about the future
We must empower them as much as possible and allow them choices as appropriate
Preparing for hospitalization
Prevent separation from parents
Make their room a home away from home
MInimize everyone’s loss of control
Promote freedom of movement, particularly with adolescents
Maintain child’s routine as much as possible
Encourage independence (self care)
Help them understand whats going on using simple language
Promote plat to teach the children and help the parents learn what’s going on. Demonstrate things you are going to do
Distract children, use treatment room appropriately so their room stays a safe place
Prevent and minimize fear about pain and imagery
Positive effect of Hospitalizations
Can strengthen family relationship
Offer educational opportunities
Help child become independent and self reliant and gain self mastery
Cultural competency
Be sensitive to cultural differences (Culture: a particular group with its own set of values, beliefs, norms, patterns that are learned, shared, and transmitted from one generation to another)
Be aware and appreciate cultural values of patient and family
Have knowledge
Collect data that is important in working with families of different culture
Encounters can happen indirectly or directly
Have desire to be engaged and sincere in wanting to learn more about other cultures
May be rituals, diets, and alternative therapies that are important to family in care of the child
Thought process must extend to spirituality, and the need to be aware and sensitive aof dealing with other religious beliefs and practices
What is pain
Whatever the child says it is and exists whenever the child says it does
Pay attention to the child: look at them objectively, listen to them subjectively in regard to their description of pain
If a procedure is invasive it will hurt whether the child says it does or not, still requires the same treatment
Pedi pain experiences
Procedure related pain: dressing changes, IV line placement, PT session
Operative pain
Trauma associated pain
Acute and Chronic pain from illness or injury
All influence the child’s future response to pain
Fear and anxiety have such a large effect in pedi pt. especially procedural pain. Provide adequate analgesia, especially for the first procedure as this will highly influence future pain perception for child
Assessment of Pedi pain
Report of pain is the most reliable diagnostic measurement of pain
Behavior and physiologic measures are also used to evaluate pain in infants, non-verbal children
Pain assessment is individualized and not one patient is the same
Know your options: if the medication doesn’t work, then know your backup, tailor according to the patients response
Evaluate to know their response
Influential factors in assessing Pedi pain: take into consideration
Age: how pain is communicated
Developmental level
Past experiences with pain: can affect their future perception of pain, control it the first time
Socio-cultural difference in attitudes toward pain and how child expresses pain
Anxiety and fear and fatigue: all increased sensitivity to pain
Cognitive impairment: may affect child’s ability to report pain
Family and friends may decreased sensitivity to pain by staying with the child
Personal genetic wiring for pain
Pain free me
Multidisciplinary approach
Nurse must utilize proper assessment techniques and tools
Work closely with: Physicians, Pain specialist (pedi team), Anesthesia, Child life specialists
Ranges of pain
Pain level ranges from a scale of 0-10
Pain score will determine the appropriate intervention
Mild: 1-3 (non-pharmacological methods)
Moderate: 4-6 (meds)
Severe: 7-10 (meds)
Combined pharmacological and non-pharmacological methods for best pain relief
Neonate characteristic facial responses to pain
Bulged brows, eyes squeezed shut, furrowed nasolabial creases, open lips, pursed lips, stretched mouth, taut tongue, quivering chin
Neonatal physiological response to pain
Increased BP
Decreased arterial saturation
Older children and pain
Important to note their body posture matches what they are telling you
Sometimes they won’t tell you they have pain because they don’t want to stay in the hospital longer and other times they will tell you they are in severe pain but are not showing it.
It is our job to assess and start with non-pharmacological methods and determine what can be used to treat stated pain
Various pain scales available
Be familiar with your hospital’s policies
Pain scales are different depending on the child’s age, verbal/nonverbal
Various neonatal behavioral pain scales
PIPP
CRIES
NIPS aka N-PASS
NFCS
PIPP
behavioral measure of pain for premature infants
CRIES
Neonatal postoperative pain scale
Pain is rated on a scale of 0-10 and the behavior indicators include: crying, changes in VS, expression, and altered sleeping patterns
Used for 32 weeks of gestation to 20 weeks of like
NIPS aka N-PASS
Used to measure pain in preterm and full term neonates
NFCS
Used for assessing post-op pain in infants
Other behavioral pain scales
FLACC
COMFORT
FLACC
Measurement used to assess pain for children between the ages 2 mo - 7yr or individuals that are unable to communicate their pain from post-op pain
COMFORT
ICU setting
Also used for infants
Pain rating scales for children
Children from 3-7 may comprehend how to use these
Visual scales should be used for children > 3 (FACES, VAS, OUCHER, WONG-BAKER)
FACES
Drawings of happy or sad faces to depict levels of pain
VAS
Visual analog scale
Used for 7 years and older
May be effective in children as young as 5
Rate pain on a scale of 0-10, the child points to the number that best describes their pain
OUCHER
Ages 3-12yr
Ethnically based self reporting tool
3 versions: Caucasian, AA, Hispanic
Used to help child identify with something that looks like them
Ask them to state exactly where the pain is
Don’t use words like happy or sad to describe pain
0: no hurt at all
2: little bit of hurt
4: little more hurt
5: pretty much hurt
6: biggest hurt you can ever have
Ask the child to point to the picture that corresponds with what they are feeling and document accordingly
WONG-BAKER
0-10 with faces
Objective data for assessment and evaluation of pain
Facial expression (grimace, wrinkled forehead, eyes closed shut)
Body movement (restlessness, pacing, guarding)
Moaning and crying
Decreased attention span
Vital signs: objective part of the whole picture
Subjective data for assessment and evaluation of pain
Use the specific words that the child used to describe the pain When did your pain start? Where is your pain? Can you rate your pain? What makes your pain better/worse? Does anything else hurt? What does the pain feel like?
Physiological signs of pain
Acute phase: increased HR, BP, diaphoresis
The body’s normal response when revved up is to calm down
Chronic pain will not have a physiological difference
Look at the whole picture: objective data, subjective data, physiological measurements
Pain management
Unrelieved pain can lead to potential long term physiological, psychological and behavioral consequences
Use both pharmacological and non-pharmacological measures
Non-pharmacological measures can help reduce perception of pain, decrease anxiety and provide a sense of control
Non-pharmacological measures used in pedi pain
Positioning: comfortable, not laying on side where they had surgery, use pillows to guard area
Reinforcing breathing and relaxation techniques
Providing Ice or heat to swollen or injured area
Maintaining calm environment
Music therapy
Pet therapy: shown to decrease patients pain, anxiety, and increased their healing
Splinting: stiffening of a body part to avoid pain caused by movement of the part, as from a fracture or other injury, use pillows for positioning
Cluster your care
Offering warm blankets
Assisting with guided imagery
Offer distractions
Provide comfort with physical contact
Administer sucrose pacifiers for infants during procedure
Various Routes for pain management
PO IV PCA/PNCA Epidural Refrigerant sprays Transmucosal Transdermal Topical
Pain management: PO
First choice when available
Tylenol: mild to moderate pain
Ibuprofen: mild to moderate pain
Tylenol #3: (combo of tylenol and codeine): moderate to severe pain
Pain management: IV
Morphine: severe pain
Fentanyl: severe pain
Dilaudid: severe pain
Pain management: PCA/PNCA
Patient controlled, parent controlled, nurse controlled analgesia
Morphine: moderate to severe pain
Hydromorphone: moderate to severe pain
Fentanyl: moderate to severe pain
Pain management: Epidural
Ropivacaine
Levobupivacaine
Pain management: Refrigerant sprays
Ethyl chloride
Fluoromethane
Pain management: Transmucosal
Oralet (fentanyl)
Pain management: Transdermal
Fentanyl or Morphine patch: know where its located on your patient and how often it needs to be changed
Pain management: Topical
EMLA
LMX
Pharmacological Management of Pain: Non opioids
Mild to moderate pain or in addition to opioids for severe pain
Acetaminophen is very common IV, PO, PR
Pharmacological Management of Pain: NSAIDS
Mild to moderate pain Puts the patient at risk for bleeding: must get baseline CBC and monitor for bleeding Ibuprofen Ketorolac Naproxen
Pharmacological Management of Pain: Opioids
For moderate to severe pain
Combo: Acetaminophen and codeine: Tylenol #3 (remember theres a limit to amount of tylenol)
Combining an opioid and non opioid medication treats pain peripherally and centrally, offers greater analgesia with less A/E like respiratory depression, constipation and nausea
Morphine is the gold standard and most commonly Rx
Hydromorphone
Fentanyl
Methadone
Tramadol
Meperidine
Pharmacological Management of Pain: PCA
Used to manage post-op pain, pain from injury, and chronic conditions
2 nurse check
Know how the dr orders it: patient controlled, parent controlled, nurse controlled
MD must order: Medication, Program settings, Rate/dose, Bolus volume (if the patient is allowed to have for breakthrough pain), Maximum allowed hourly dose, Lock out time (the time the patient has to wait before being able to push the administration button again)
Narcotic Side effects
Respiratory depression #1
Constipation (order stool softener, monitor bowels, hydration)
N/V (can take antiemetics before)
Dizziness (educate about getting up slowly and resting both feet on ground before standing)
Itching (might need to give benadryl before)
Increased sleepiness (can be from too much benadryl: adjust dose)
Have these at the patient’s bedside when on narcotics
15L O2 flow regulator
Various O2 delivery systems
Ambu bag with appropriate size face mask (need at least 15L to fill up Ambu bag that will be attached to O2 flow regulator
Code sheet (patient could go into respiratory and cardiopulmonary failure)
PRN order for Naloxone if respiratory depression occurs
Continuous monitoring for patients on narcotics
Cardiopulmonary and pulse ox to monitor for respiratory depression
Evaluation of effectiveness of pain therapy
Need to evaluate 30 minutes to an hour after administration for effectiveness
If not effective then it needs to be changed
If it works on one patient it doesn’t mean it will work on the next
Know all options available to you and the safe dosages